Archive for April, 2015

If Dr. Pridgen is right, his protocol for treating fibromyalgia could end up turning the medical world’s conception of FM (and perhaps even chronic fatigue syndrome) on its head. The first treatment trial had good results but they didn’t exactly turn the FM world upside down. Geoff Langhorne asked him about that in an interview a couple of months ago and I followed up with my own questions.

A confident Dr. Pridgen explained why the first trials result were good but not earth-shattering and why the next trial results will be better. First some background.

How it Happened

“It was never my intention to be involved in Fibromyalgia” William Pridgen

Pridgen didn’t start out to treat fibromyalgia – he was simply trying to get at what was causing the diarrhea/constipation and abdominal pain in his patients. Both he and his mother – a virologist – recognized that the pattern he kept seeing –stubborn symptoms which got better with treatment then got worse, and then better and then worse – could reflect a virus getting reactivated, then knocked down, reactivated then knocked down. Throw in the fact that his patients gut problems typically got worse during stressful events and a herpesvirus infection became a viable option.

The pattern of remission and then relapse, particularly, after stressful situation, suggested herpesviruses.

Pridgen started off giving a couple of his patients a single antiviral herpesvirus drug. The fact that some of the patients did get better encouraged him, but it was not until he combined it with the anti-inflammatory Celexicob (Celebrex) that he really began to see results.

The big surprise was that his patients were reporting relief from a whole panoply of other symptoms. Their fatigue, their headaches, their muscle and joint pains, their sleep problems, their difficulty relaxing – all were improved. By the time twenty or thirty patients had reported this he really began to take notice.

“Holy crud!” in the interview he stated, “I discovered something.”

He switched gears and began offering the drug combo to people with chronic fatigue syndrome and fibromyalgia. He lambasted the idea that fibromyalgia or chronic fatigue syndrome are difficult diagnoses to make. As soon as he knew what these illnesses looked like, he said, anyone working in his office could spot them immediately.

Fixing What’s Broken

Patients tended to sporadically improve early with the full effects showing up after about three months. He wasn’t just treating herpesvirus infections, however. Asserting that these diseases “break things”, he also worked on their treatment resistant sinusitis, acid reflux, thyroid issues, insomnia, anxiety, and depression.

Pridgen asserted it’s necessary to fix what else is broken for his protocol to have full effect.

In fact, his first step was to figure out what was broken and fix it and then put them on the drug combo “. He said “if you’ve done a good job with the first half” then 12 to 14 weeks into the treatment program a “switch” often gets flipped with people feeling a whole lot better.

Geoff then asked a great question – would you characterize this as a cure or a successful treatment? Pridgen stated that you can’t “cure” or eliminate viruses, but that he did feel that his treatment protocol was getting at the core of the disease. Note, however, that Dr. Pridgen did put that qualifier – “If you’ve done a good job with the first half” – in. It’s important to treat the depression or generalized anxiety disorder, symptomatic gallbladder disease, severe reflux and chronic nonseasonal sinusitis, etc. for his combination treatment to optimally work.

His protocol, he believes, is much more effective at symptom reduction than the drugs currently approved for fibromyalgia. He does not feel those meds get at the core of the disorder: his does.

Herpes Simplex Virus-1

The predominant virus he believes that is causing the pain in fibromyalgia is herpes simplex virus-1 (HSV-1). HSV-1 has been put in the “fever-blister” category; it causes some unpleasant symptoms and nothing more. Pridgen believes that view and the accompanying attitude of benign neglect towards the virus HSV-1 are disappearing.

HSV-1, it turns out, isn’t always so benign, after all. Yes, the initial infection is usually mild. And yes, essentially everyone, including healthy people, is exposed to and carries HSV-1 in their body.

HSV-1 hangs out in the neurons. In susceptible people that could be a problem.

Like the other herpesviruses, however, HSV-1 persists in the body hanging out in the neurons. After the initial infection, HSV-1 is able, in some people, to become reactivated, travel up the axon of the neuron to the nerve centers – waiting to be reawakened by a stressor.

Studies indicate that almost any stressor including colds, eczema, menstruation, emotional and physical stress, stomach upset, fatigue or injury can reactivate it. It can cause encephalitis and blindness, and some evidence suggests it’s associated with Alzheimer’s disease.

Vaccines for HSV-2, a close cousin to HSV-1, are being worked on. If HSV-1 does end up being the cause of fibromyalgia, Pridgen believes widespread HSV-2 vaccination could, just as vaccines have put an end to measles, chickenpox, hepatitis and other viral illnesses, help put an end to fibromyalgia. A vaccine, by the way, could also potentially help some people who already have fibromyalgia much like the shingles vaccine helps people with Varicella Zoster reactivation.

The First Trial

“We didn’t get a 60-70% efficacy, because it wasn’t our ideal dose and a lot of patients had other conditions they couldn’t get fixed in a trial like that.”

If you’ve been following the Pridgen story you’ve probably heard of people who’ve tried the Famvir/Celebrex combination who’ve done well and others who haven’t. Pridgen addressed the variability in results in his protocol by asserting that the doses aren’t set and that many of the participants had more than fibromyalgia to deal with.

The trial was less restrictive than most other phase 2 (FDA approved) FM trials where men or people with severe depression weren’t allowed to enroll. He said they pretty much let everybody with FM in.

He also stated that if the patients failed to commit to fixing the secondary problems they didn’t do as well. The FDA also required only one dose be used in the trial – and that dose was not their “favorite” one.

Fifty-three percent of the patients in the trial had at least a thirty percent reduction in pain. That’s a good but not great figure, but Pridgen noted that almost forty percent had at least a fifty percent reduction in pain – and that’s a very good figure for FM. Already their stats, he stated, may prove to be better than the three FDA approved drugs for FM – and he hasn’t been able to use the dose he ultimately intends to market. He stated that some of the world class experts on IMC’s scientific advisory board have said they had “never seen pain data like this” for FM before.

The Next Trials

The next phase three trials, though, will be slightly more selective as the fibromyalgia patients will not have as many “extra conditions”.

It’s going to take time to raise the money and then do two phase III trials – which can be run side by side. While there may be one dose that works best for the most people, Pridgen asserted that no dose is perfect for this variable population and they’ll probably do a dose-ranging study to get at the variability.

They’re trying to get FDA to fast-track the next trials. My guess is that patient enrollment will not be a problem; they expected it to take nine months to enroll the last study and they did it in three.

When asked how the phase three trials are coming Pridgen stated, “We’re moving as fast as we can….This is not an easy process.”

Confident

“I feel very confident that the next two trials will be far more impressive”.

Dr. Pridgen appears to be utterly confident he’s on the right track. He said he’s seen a 1,000 plus FM patients and an equal number of chronic fatigue patients.

Prigen asserts many people have gotten well using his protocol.

“If a patient does what we tell them to do and they jump through the appropriate hoops it’s unbelievable what happens to these people – they do so much better” Skip Pridgen

When the Blue Ribbon Project came to Tuscaloosa, it was the only place, he said, they saw people getting better.

He said he’s seen “countless” patients get well and go on with their lives, including very ill patients. “I’ve had some tremendously ill patients who get their life back….get back to working again.”

They come from all over. He gets the protocol started and then refers them back to their physicians. His Canadian and Australian patients have a good chance of continuing with the protocol because their physicians are more open minded, but the Brits often run into a wall so unless they can cross the Atlantic, presently they are receiving little support from their own medical profession.

Dr. Pridgen Talks

When do you expect the study to be published?

Dr. Carol Duffy is feverishly working on the manuscript and should be submitting it for publication this summer, hopefully in one of the premier pain journals.

How did you, a surgeon, end up treating people with gut problems?

Many general surgeons perform endoscopies in their practice of medicine.

How did you get the idea to combine the antiviral with an anti-inflammatory?

I was merely giving them a NSAID for their joint pains, and serendipitously noticed the two drugs when combined had unexpected benefits. I’d never heard of anti-inflammatories used to hit viruses before. Virologists have known for two decades, though, that NSAID had antiviral properties.

You presented a very different model of fibromyalgia at the Rheumatology Conference than rheumatologist are used to. I don’t know if anyone has looked at fibromyalgia as a herpesvirus disorder let alone treated people with antivirals. What kind of reception did your talk receive?

Lot’s of questions, none too difficult to answer and generally it was well received even if the attendance was not ideal.

Pridgen and Duffy believe three sites in the body may be particularly affected in fibromyalgia: the gut, the vagus nerve and the sinus area

I know someone who couldn’t tolerate the Famvir but did very well on Celebrex for six months when everything fell apart again.

There are other options, and if his physician had reached out to me, I would have given the physician everything they needed to help that patient.

What can you say about the gut tissue biopsy results?

The preliminary data was presented a little over a year ago at an international virology meeting, and for patients who have FM 100% of those patients have HSV-1 data in their biopsies and 80% have a protein that is found only in cells that are actively infected with HSV-1.

If HSV-1 is found in the guts of FM patients is it your guess that it’s probably reactivating elsewhere?

The vagus nerve is the nerve that controls the gut and the virus lives in its ganglion. We postulate that there are two other major sites, the sinuses, and the urinary bladder, that are also likely sites of chronic reactivation.

If it’s active in the gut would you expect to see an increased incidence of cold sores in FM?

Approximately 30% of the population suffers from cold sores. If you go to the innovativemedconcepts.com site you will be able to watch a couple of video’s that explain this better.

Has Pridgen cracked at least part of fibromyalgia? Time will tell. The big studies are next…

You tried several different combinations of drugs and Famvir turned out to be the antiviral of choice for the fibromyalgia patients in your study. Do you have any idea why Famvir was more effective than the other drugs?

(Dr. Pridgen said that’s a trade secret for now.)

In your experience are people who improve dramatically able to get off the drugs and maintain their improvement for a considerable amount of time?

Absolutely not! The moment they stop the meds the next time they are severely stressed the condition returns. You can’t stop diabetes, hypertension, and cholesterol medications and you can’t stop these.

An anachronism from the day it was published, the 17 page, large-type Toolkit looked like a cartoon copy of how to identify and treat ME/CFS next to the 42 page, densely detailed IACFS/ME Primer released in 2012. It was a Toolkit with decidedly few tools.

An anachronism from the day it was published, the Toolkit was finally knocked out by the IOM report

The limited recommendations in the Toolkit, and before that on the CDC website, have been a source of frustrations for patients and knowledgeable medical providers for many years. It’s been exhibit one for patients wishing to portray the CDC as being out of touch.

The Toolkit stated that a team of doctors and mental health professionals and physical therapists were best suited to treat ME/CFS. It emphasized therapies that addressed coping, symptoms and activity management.

Several assertions in the Toolkit that came out of the CDC’s randomly sampled population studies using the Empirical Definition people were controversial. They included statements that people ME/CFS are more likely to be obese, experience insulin resistance and have metabolic syndrome.

To its credit, the Toolkit did note the need for lower doses of medication, asserted that antidepressants were effective only for those with clinical depression and, while promoting exercise, provided substantial warnings about it.

Cognitive behavioral therapy (CBT), graded exercise therapy (GET) and sleep, however, were the only treatments covered in any kind of depth. While the Toolkit stated exercise programs should not increase patients symptoms, it also suggested that exercise therapy would ultimately enable people with ME/CFS to “go about their daily life(s)”.

The Toolkit has been buried deep in the CDC’s website.

In contrast to the Primer which identified what are now accepted as core symptoms of the disorder, the Toolkit stuck with symptoms associated with the 20 year old Fukuda definition. The Toolkit identified seven co-morbid condition – several of which are questionable; the Primer – 48. The Toolkit identified ten illnesses that can mimic ME/CFS; the Primer – 55.

The Toolkit provided no specific recommendations on drug treatments; the Primer provided 49 recommendations. The Toolkit provided no recommendations for managing pain; the primer provided recommendations on both non-drug and drug approaches to pain. The Toolkit provided no recommendations on cognitive issues, orthostatic intolerance, gut problems, etc. The list goes on and on.

The Toolkit has influenced the treatment recommendations on many major medical websites. Now, in response to the IOM Report, it’s essentially gone. You can find an archived version of it on the website, but the CDC is clearly not standing by the Toolkit anymore.

It’s abrupt removal suggests major changes are in store. With the IOM report proposing new diagnostic protocols that was expected. It couldn’t have happened too soon.

Columbia University just published groundbreaking results of the first spinal fluid study to compare ME/CFS with Multiple Sclerosis and healthy controls. For almost his entire career treating CFS patients, Dr. Daniel Peterson has been working toward this day.

Simmaron Research, founded by Dr. Peterson, was a key collaborator in this study, along with Konstance Knox Ph.D. of Coppe Healthcare. Drs. Peterson and Knox provided the spinal fluid samples, and Simmaron’s Research Manager Gunnar Gottschalk did clinical coordination. Drs. Mady Hornig (lead author) and Ian Lipkin (senior author), who run Columbia’s Center for Infection and Immunity, designed the study and led the sample and data analyses. Many thanks are due all the collaborators and especially the Chronic Fatigue Initiative and Evans Foundation for funding this novel work.

Cerebral spinal fluid is a colorless fluid that surrounds and cushions the brain and spine. Constantly being produced and absorbed it is fully replaced about four times a day. It provides immunological protection and removes metabolic wastes from the brain.

Lumbar punctures such as those used in this study are primarily used to diagnose neurological disorders.

In several ways, this study distinguished itself from other spinal fluid studies in chronic fatigue syndrome. It examined a more comprehensive cytokine panel (n=51), did more sophisticated statistical analyses (logistic regression/network analysis) and included a multiple sclerosis group as a control. With ninety-one subjects, it was a large sample size for a spinal fluid study (32 ME/CFS patients, 40 MS patients, 19 controls) and it was suitably complex.

Highly Significant Results

Major differences were found. With all the central nervous system problems present in MS, we expect MS would be different from healthy controls. The levels of over half of the cytokines tested (26/51) in the MS group vs the controls were significantly different. An almost equal degree of difference, however, also occurred in the ME/CFS group. Almost half the immune factors tested (23/51) were significantly different in the ME/CFS patients relative to the healthy controls.

Highly significant differences in immune factor levels (p<.0003 or less) were found in 13 cytokines in MS group vs healthy controls, in 4 cytokines in ME/CFS vs healthy controls, and in 8 cytokines comparing ME/CFS to MS.

Immune Exhaustion

Most immune molecules were lower in both the ME/CFS and MS patients

The immune system is a complex place. Cytokines have a role in both producing and controlling inflammation. Some evidence points to ME/CFS being an inflammatory disorder, and there’s no doubt that multiple sclerosis is an inflammatory disorder. Interestingly, the cytokine levels in the MS patients spinal fluid were even lower than those in the ME/CFS patients.

In general both MS patients and ME/CFS trended in the same direction – mostly reduced cytokine levels relative to the controls – but the immune dysregulation was very different. With twenty-three immune factors differing between the ME/CFS and MS patients, a case could be made that the ME/CFS and MS groups differed the most immunologically. The researchers stated ME/CFS patients demonstrated a “markedly greater degree of CNS immune activation” than the MS group.

People in the current study had had chronic fatigue syndrome for about seven years. The relatively low cytokine levels found parallel those found in the longer duration patients in the large blood cytokine study the Columbia researchers recently completed.

“I think what we’re seeing is an immune system exhaustion over time,” Dr. Hornig speculated in HealthDay.

Chemokines, Infections and CNS Damage

Scientists at Columbia … identified a unique pattern of immune molecules in the cerebrospinal fluid of people with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) that provides insights into the basis for cognitive dysfunction—frequently described by patients as “brain fog”

Chemokines are of special interest in neuroinflammation because these very small proteins regulate immune cell entry into the brain. When an infection occurs, they draw immune cells into the brain by increasing the permeability of the brain blood barrier. The microglia and astrocytes are the primary chemokine producers in the brain.

High CXCL10 levels have been associated with infection or demyelination

Two chemokines (CCL11 and CXCL10) were increased in both the MS and ME/CFS groups with much higher levels of both found in the MS group.

CXCL10 clears the way for the entry of natural killer cells and T lymphocytes into the brain. It is often prominently expressed in the CNS in response to viral infection.

As always the immune system walks a fine line. Too little chemokine expression and a deadly infection can take root. Too much chemokine expression and brain damage and seizures can result. While CXCL10 plays an important role in combating viral infections, excessive CXCL10 levels can cause neuron die off and trigger a immune-mediated demyelinating disease.

Demyelination is a major problem in MS but is only a possibility at this point in ME/CFS. A small recent Stanford study suggested myelin abnormalities along with white matter atrophy may be present in ME/CFS. .

Not surprisingly, CXLC10 clearly has an impact on symptoms. Neutralizing CXCL10 even during a persistent infection can greatly reduce symptom severity.

Allergic Response, Eotaxin and Brain Fog

“These immune findings may contribute to symptoms in both the peripheral parts of the body and the brain, from muscle weakness to brain fog.” Dr. Mady Hornig

IL1ra is supposed to tamp down an allergic response as well. The network analysis in this study suggests that it’s not working so well in ME/CFS patients. The inverse relationship between IL1ra and CSF2 (GMCSF) levels in the ME/CFS patients, indeed, suggested an allergic response was underway. Reduced CSF2 levels were found in a prior ME/CFS spinal fluid study as well.

Then there is eotaxin (CCLII). Eotaxin recruits white blood cells called eosinophils that are involved in producing an allergic response in the brain. The logistic regression suggested increased levels of eotaxin (and decreased levels of IL1b) are highly associated with “ME/CFS caseness”.

Eotaxin has been associated with cognitive declines and reduced neuron growth in mice.

Eotaxin is not a chemokine one particularly wants to have around. Increased eotaxin levels have been associated with impaired learning, memory deficits and reduced neuron production in mice as they age. Introducing eotaxin into the CNS of young mice reduces neuron production. (At the last IACFS/ME Conference, the CDC reported reduced telomere length – another possible sign of increased aging – was present in ME/CFS.)

“…we now identify systemic immune-related factors (eotaxin) as potentially critical contributors to the susceptibility of the aging brain to cognitive impairments”. Villeda et. al. 2011 – From a mouse study published in Nature

One doesn’t think of allergy in terms of the central nervous system, but the authors reported that allergic processes could be indicative of a central nervous system infection. The chemokines upregulated in the ME/CFS patient’s spinal fluid have been associated with microglial activation and central nervous system infections.As the publication notes, “Persistent secretion of cytokines by activated microglia, brain immune cells of macrophage-monocyte lineage, may contribute to this pattern.”

Networks Awry

“The inverse relationship we found between IL1ra and CSF2 in the CSF of cases using a network analysis approach suggests that neuroimmune responses may be shifted toward allergic or Th2 (autoimmune) patterns in the CNS of individuals with ME/CFS.”

The Hornig/Lipkin team also found evidence of disturbed “networking” in ME/CFS; i.e. immune cells communicating strangely. IL-1ra is an interleukin that prevents cells with IL-1 receptors from producing the powerful pro-inflammatory cytokines IL-1A or IL-1B. It stops that part of the immune response in its tracks, but the network analysis suggested it wasn’t doing that in ME/CFS.

Summing Up

The fact that the alterations in the immune factors in the ME/CFS were almost as extreme as in multiple sclerosis – a disorder characterized by severe central nervous system dysfunction – suggests a major pathology is present in the central nervous systems of ME/CFS patients.

The low cytokine levels suggest that some sort of immune exhaustion – caused by an infection or by immune upregulation – is present in ME/CFS. These findings parallel those of the recent Hornig/Lipkin study suggesting that immune up regulation early in the disorder may lead to immune burnout later on.

Several of the immune factors in the ME/CFS patients spinal fluid suggest an allergic type of reaction may be occurring in their CNS. A similar finding is also found in some central nervous system infections; i.e. an infection could be driving this process.

The immune factor most identified with the ME/CFS patients has been associated with cognitive declines, aging and reduced neuron production.

Moving Forward

“Diagnosis of ME/CFS is now based on clinical criteria. Our findings offer the hope of objective diagnostic tests for disease as well as the potential for therapies that correct the imbalance in cytokine levels seen in people with ME/CFS at different stages of their disease,” adds W. Ian Lipkin, MD, John Snow Professor of Epidemiology and director of the Center for Infection and Immunity.

Dr. Daniel Peterson

Early on, MS didn’t have biomarkers or diagnostic tests, and it had skeptics like CFS does. Later it was diagnosed by specific proteins in spinal fluid. Now there are FDA-approved treatments.

ME/CFS patients often have central nervous system symptoms, like cognitive dysfunction, balance problems, and nerve and pain issues. Those symptoms convinced Dr. Peterson many years ago that spinal fluid may hold the key to understanding the disease. His perseverance helped make this study possible.

Columbia University’s press release stated:

“There is precedent for use of human monoclonal antibodies that regulate the immune response in a wide range of disorders from rheumatoid arthritis to multiple sclerosis. However, the researchers note, additional work will be needed to assess the safety and efficacy of this approach.”

We need more research to translate these unprecedented findings into diagnostics and treatments.